Risk of second primary tumors in men diagnosed with prostate cancer: a population-based cohort study

NCCN Guidelines Insights: Survivorship, Version 2.2020

The NCCN Guidelines for Survivorship provide screening, evaluation, and treatment recommendations for consequences of adult-onset cancer and its treatment, with the goal of helping healthcare professionals who work with survivors, including those in primary care. The guidelines also provide recommendations to help clinicians promote physical activity, weight management, and proper immunizations in survivors and facilitate care coordination to ensure that all of the survivors' needs are addressed. These NCCN Guidelines Insights summarize additions and changes made to the guidelines in 2020 regarding cardiovascular disease risk assessment and screening for subsequent primary malignancies.

Second Cancers in Patients With Locally Advanced Prostate Cancer Randomized to Lifelong Endocrine Treatment With or Without Radical Radiation Therapy: Long-Term Follow-up of the Scandinavian Prostate Cancer Group-7 Trial

BACKGROUND

Curative radiation therapy (RT) constitutes a cornerstone in prostate cancer (PC) treatment. We present long-term follow-up estimates for second cancer (SC) risk and overall survival (OS) in patients randomized to hormone therapy (ET) alone or combined with 70 Gy prostatic RT in the Scandinavian Prostate Cancer Group-7 (SPCG-7) study. We explored the effect of salvage RT (≥60 Gy to the ET group) and reported causes of death.

METHODS AND MATERIALS

The SPCG-7 study (1996-2002) was a randomized controlled trial that included 875 men with locally advanced nonmetastatic PC. In this analysis, including data from the Norwegian and Swedish Cancer and Cause of Death registries for 651 Norwegian and 209 Swedish study patients, we estimated hazard ratios (HRs) for SC and death, and cumulative incidences of SC.

RESULTS

Median follow-up of the 860 (431 ET and 429) ET + RT patients was 12.2 years for SC risk analysis and 12.6 years for the OS analysis. Eighty-three of the Norwegian ET patients received salvage RT, and median time to salvage RT was 5.9 years. We found 125 and 168 SCs in the ET and ET + RT patients, respectively. With ET alone as reference, ET + RT patients had an HR of 1.19 (95% confidence interval [CI], 0.92-1.54) for all SCs and 2.54 (95% CI, 1.14-5.69) for urinary bladder cancer (UBC). The total number of UBC was 31 (23 in ET + RT; 8 in ET), and the vast majority (85%) were superficial. The HR for SC in salvage RT patients was 0.48 (95% CI, 0.24-0.94). Median OS was 12.8 (95% CI, 11.8-13.8) and 15.3 (95%, CI 14.3-16.4) years in the ET and ET + RT groups, respectively. Compared with ET alone, the risk of death was reduced in ET + RT patients (HR, 0.73; 95% CI, 0.62-0.86) and in ET patients receiving salvage RT (HR, 0.44; 95% CI, 0.30-0.65).

CONCLUSIONS

Although the risk of UBC was increased in PC patients who received RT in addition to ET, this disadvantage is outweighed by the OS benefit of RT confirmed in our study. The risk of SC, and especially UBC, should be discussed with patients and be reflected in follow-up programs.

Associations Between Prediagnostic Concentrations of Circulating Sex Steroid Hormones and Esophageal/Gastric Cardia Adenocarcinoma Among Men

Background

Esophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) are characterized by a strong male predominance. Concentrations of sex steroid hormones have been hypothesized to explain this sex disparity. However, no prospective population-based study has examined sex steroid hormones in relation to EA/GCA risk. Thus, we investigated whether prediagnostic circulating sex steroid hormone concentrations were associated with EA/GCA in a nested case-control study drawn from participants in three prospective cohort studies.

Methods

Using gas chromatography-mass spectrometry (GC-MS) and electrochemiluminescence immunoassay, we quantitated sex steroid hormones and sex hormone binding globulin, respectively, in serum from 259 EA/GCA male case participants and 259 matched male control participants from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study, and Cancer Prevention Study II Nutrition Cohort. Multivariable conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between circulating hormones and EA/GCA risk. All statistical tests were two-sided.

Results

Higher concentrations of dehydroepiandrosterone (DHEA) were associated with a 38% decreased risk of EA/GCA (OR per unit increase in log2 DHEA = 0.62, 95% CI = 0.47 to 0.82, Ptrend = .001). Higher estradiol concentrations were associated with a 34% reduced risk of EA/GCA (OR = 0.66, 95% CI = 0.45 to 0.98, Ptrend = .05), and the association with free estradiol was similar. No other associations between baseline hormone concentrations and future EA/GCA risk were observed.

Conclusions

This study provides the first evidence that higher concentrations of circulating DHEA, estradiol, and free estradiol may be associated with lower risks of EA/GCA in men.

Do Sex Hormones Underlie Sex Differences in Cancer Incidence? Testing the Intuitive in Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EA) incidence is 4-8 times higher in men compared with women, yet this imbalance cannot be explained by known risk factors. This issue of The American Journal of Gastroenterology features results from only the second prospective study to assess whether prediagnostic sex steroid hormones underlie sex differences in EA. Xie et al. report that higher concentrations of testosterone and luteinizing hormone were associated with decreased EA risk. While contrary to the long-standing hypothesis that testosterone increases EA risk, these important results lay a foundation for additional studies to further elucidate this intuitive, intriguing, and evolving hypothesis.

Does radiotherapy increase the risk of colorectal cancer among prostate cancer patients? A large population-based study

Objective: The survival of prostate cancer (PC) patients after radiotherapy (RT) has improved over time, but it raises the debate of increased risk of secondary colorectal cancer (SCRC). This study aimed to assess whether RT for PC treatment increases the risk of SCRC in comparison with radical prostatectomy (RP). Methods: A population-based cohort of PC patients treated only with RT or only with RP between January 2007 and December 2015 was identified from the Taiwan Cancer Registry. The incidence rate of SCRC development was estimated using Cox regression model. Results: In this study, total 8,797 PC patients treated with either RT (n = 3,219) or RP (n =5,578). Patients subjected to RT were elder (higher percentage of 70≧years, p < 0.0001) and more advanced clinically (stage III: 22.90% vs. 11.87%; stage IV: 22.15% vs. 13.80%, p < 0.0001), compared to those subjected to RP. More patients subjected to RT had a much higher percentage of autoimmune disease (22.34% vs. 18.75%, p < 0.0001) and osteoarthritis and allied disorders (16.31% vs. 12.98%, p < 0.0001). Besides, RT patients had a higher percentage of underlying Crohn's disease (0.25% vs. 0.05%, p = 0.0230). Although almost all selected factors were not statistically significant, they presented the positive risk of SCRC for those under RP compared with those among RT. Besides, for PC patients in clinical stage I and II, patients with RP may have borderline significantly protective effects of SCRC compared with those under RT (stage I, HR: 0.14; 95% C.I.:0.01-1.39; p = 0.0929; stage II, HR: 1.92; 95% C.I.:0.93-3.95; p = 0.0775). Kaplan-Meier curves for a 3-year-period, which demonstrated no statistical difference in the risk of SCRC free between PC patients undergoing RT and RP (p = 0.9766). Conclusion: Whether or not pelvic RT for PC is associated with an increased risk for SCRC on a population-based level remains a matter of considerable debate. From a clinical perspective, these PC survivors should be counseled accordingly and received continued cancer surveillance with regular colonoscopy follow-up.

Impact of a Changing Population Structure and Clustering of Cancer in Prostate Cancer Patients Depending on a First-Degree Family History

INTRODUCTION

In the last century, there have been major changes within the population structure in Germany. The aim of this study was to determine the impact of a changing population structure on identification of familial prostate cancer (PCa), and to investigate how many and which types of other cancers have occurred in patients and their first-degree relatives.

MATERIALS AND METHODS

A total of 19,540 patients were evaluated in a prospectively collected PCa family database and divided into four birth cohorts: 1925-1934 (cohort A), 1935-1944 (cohort B), 1945-1954 (cohort C), and 1955-1964 (cohort D). Other primary cancers and cancers of first-degree relatives were evaluated.

RESULTS

The percentage of PCa patients with ≥2 sons declined (A: 28.9% to D: 21.6%). The percentage of patients whose fathers lived for ≥65 years increased (B: 64.2% to D: 73.0%). Malignancies of the skin, the urinary tract, and the lymphoid/hematopoietic tissue were more common in patients with a positive first-degree PCa family history and their first-degree relatives. Additionally, first-degree relatives reported more often neoplasms of respiratory/intrathoracic organs and the female breast.

CONCLUSIONS

A small family size, an early deceased father, and a high number of sporadic cases complicate the identification of familial PCa patients. Thus, a detailed family history should also include unaffected first-degree relatives to avoid any misclassification. Findings of other primary cancers in patients and their relatives warrant further investigation.

Effect of external beam radiotherapy on second primary cancer risk after radical prostatectomy

INTRODUCTION

We aimed to investigate the effect of radiotherapy (RT) in contemporary patients treated with radical prostatectomy (RP) compared to RP alone for non-metastatic prostate cancer (PCa) on the incidence of second primary cancers (SPCs).

METHODS

Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015), we identified patients with PCa as the only or first primary cancer, who underwent RP and RT or RP alone. Cumulative incidence plots and multivariable Cox regression models tested for SPC rate differences according to treatment type: RP and RT vs. RP alone. Subgroup analyses focused on pelvic, primary pelvic, and non-pelvic SPCs, as well as on late SPCs (>5 years after PCa diagnosis).

RESULTS

Of 152 161 patients, 7.1% (n=10 870) received RP and RT. Overall, 6.6 vs. 5.0% developed SPCs after RP and RT vs. RP alone, respectively (p<0.001). Cumulative incidence rates at 10 years after PCa diagnosis for RP and RT vs. RP were 12.0 vs. 8.7% (p<0.001), 2.0 vs. 1.2% (p<0.001), 2.1 vs. 1.3% (p<0.001), and 9.9 vs. 7.4% (p<0.001) for overall SPCs, primary pelvic SPCs, overall pelvic SPCs, and non-pelvic SPCs, respectively. Multivariable Cox regression models revealed an increased risk after RP and RT vs. RP alone for overall (hazard ratio [HR] 1.2; p<0.001), primary pelvic (HR 1.5; p<0.01), pelvic (HR1.4; p<0.001), non-pelvic (HR1.1; p<0.01), late overall (HR 1.2; p=0.01), and late non-pelvic SPCs (HR1.2; p=0.03).

CONCLUSIONS

RP with RT was associated with moderately increased risk of SPCs compared to RP alone. This observation should be thoroughly discussed at informed consent and considered during followup.

Efficacy of Synbiotics to Reduce Symptoms and Rectal Inflammatory Response in Acute Radiation Proctitis: A Randomized, Double-Blind, Placebo-Controlled Pilot Trial

Purpose: Evaluate whether the daily intake of synbiotics improves symptoms and rectal/systemic inflammatory response in patients with radiation-induced acute proctitis.Methods and Materials: Twenty patients who underwent three-dimensional conformal radiotherapy for prostate cancer were randomized to intake either a synbiotic powder containing Lactobacillus reuteri (10⁸ CFU) and soluble fiber (4.3 g) or placebo. EORTC QLQ-PRT23 questionnaire was applied before the beginning of radiotherapy and after the fifth, sixth, and seventh weeks of treatment, and the sum of both the complete (proctitis symptoms plus quality of life) and partial (proctitis symptoms) scores were compared. Fecal calprotectin was measured at Day 0 and in the fourth week of treatment, and serum C-reactive protein/albumin ratio were measured in the fourth week of treatment.Results: Both the complete and partial questionnaire score (median and range) were higher in the fifth and sixth weeks in the placebo group; there was a higher increase in fecal calprotectin in the placebo group and no difference comparing CRP/albumin ratio.Conclusions: Synbiotics reduce proctitis symptoms and improve quality of life by preventing rectal inflammation during radiotherapy for prostate cancer.

Increased incidence of second primary malignancy in patients with malignant astrocytoma: a population-based study

We identified patients diagnosed with malignant astrocytoma (MA) as the first of two or more primary malignancies between 1973 and 2015 from Surveillance, Epidemiology and End Results (SEER) database. Multiple primaries-standardized incidence ratio (MP-SIR) was calculated to quantitate the risk of second primary malignancy (SPM). We further identified the risk factors of developing SPM and factors affecting overall survival (OS) in MA patients with SPM. Our results revealed that overall risk of SPM among MA patients was significantly higher than that in general population (SIR: 1.09, 95% confidence interval (CI): 1–1.18, P<0.05). Specific sites where the risk of SPM increased included salivary gland, bone and joints, soft tissue including heart, brain, cranial nerves other nervous system, thyroid, acute non-lymphocytic leukemia and acute myeloid leukemia. Overall risk of SPM in patients aged ≤29 and 30–59 years significantly increased (4.34- and 1.41-fold respectively). Whereas patients aged ≥60 years had a significantly decreased risk of SPM. Patients in the group of latency at 36–59, 60–119 and ≥120 months carried significantly increased overall risk of SPM. Multivariate analysis revealed that age, race, marital status, WHO grade, differentiated grade of cancer tissues, latency was independent predictor of OS in MA patients with SPM, which were all selected into the nomogram. The calibration curve for probability of survival showed good agreement between prediction by nomogram and actual observation. In conclusion, MA survivors should be advised of their increased risk for developing certain cancers in their lifetime. Our study had clinical implications for the surveillance of MA survivors at risk of developing SPM.

Second cancers in radically treated Norwegian prostate cancer patients

Introduction: The aim of this registry-based cohort study was to estimate second cancer (SC) risk following radical prostate cancer (PC) treatment and evaluate if the risk was influenced by radiotherapy. Materials and methods: We collected data from the Cancer Registry of Norway on all patients with PC as first cancer diagnosis, from 1997 to 2014. Standardized incidence ratios (SIRs) for SC were calculated by comparing our cohort to the standard male population. Subdistribution hazard ratios were estimated in treatment groups, using patients treated with radical prostatectomy (RP) as reference. Results: We analyzed 24,592 radically treated PC patients. The median follow-up was 7.75 and 6.25 years in the external beam radiotherapy (EBRT) and RP-groups, respectively. SIR for SC was indifferent from the reference population in 24,592 radically treated patients, higher following EBRT, SIR 1.12 (1.07-1.17), and lower following RP, SIR 0.93 (0.87-0.99). EBRT treated patients had higher rectal and urinary bladder cancer incidences, SIR 1.38 (1.16-1.64) and 1.49 (1.31-1.69), respectively. The EBRT patients and the patients treated with radiation after RP (RT after RP) had 38 and 27% higher risk of any SC. We found higher risk of bladder cancer for all treatment groups as compared to RP patients. Only EBRT treated patients showed higher risk of rectal and lung cancer. Discussion/conclusions: In our study, we found that PC patients treated with EBRT had an increased incidence of SC compared to the general population. Patients treated with EBRT and RT after RP were found to have increased risk of SCs, using RP patients as reference. The risks of rectal and urinary bladder cancer in patients receiving EBRT were higher compared to both the general population and to patients treated with radical prostatectomy. The risk of SC should be taken into account when discussing treatment for patients and designing follow-up.

Proton versus photon-based radiation therapy for prostate cancer: emerging evidence and considerations in the era of value-based cancer care

BACKGROUND

Advances in radiation technology have transformed treatment options for patients with localized prostate cancer. The evolution of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (IMRT) have allowed physicians to spare surrounding normal organs and reduce adverse effects. The introduction of proton beam technology and its physical advantage of depositing its energy in tissue at the end-of-range maximum may potentially spare critical organs such as the bladder and rectum in prostate cancer patients. Data thus far are limited to large, observational studies that have not yet demonstrated a definite benefit of protons over conventional treatment with IMRT. The cost of proton beam treatment adds to the controversy within the field.

METHODS

We performed an extensive literature review for all proton treatment-related prostate cancer studies. We discuss the history of proton beam technology, as well as its role in the treatment of prostate cancer, associated controversies, novel technology trends, a discussion of cost-effectiveness, and an overview of the ongoing modern large prospective studies that aim to resolve the debate between protons and photons for prostate cancer.

RESULTS

Present data have demonstrated that proton beam therapy is safe and effective compared with the standard treatment options for prostate cancer. While dosimetric studies suggest lower whole-body radiation dose and a theoretically higher relative biological effectiveness in prostate cancer compared with photons, no studies have demonstrated a clear benefit with protons.

CONCLUSIONS

Evolving trends in proton treatment delivery and proton center business models are helping to reduce costs. Introduction of existing technology into proton delivery allows further control of organ motion and addressing organs-at-risk. Finally, the much-awaited contemporary studies comparing photon with proton-based treatments, with primary endpoints of patient-reported quality-of-life, will help us understand the differences between proton and photon-based treatments for prostate cancer in the modern era.

Deciphering the scalene association among type-2 diabetes mellitus, prostate cancer, and chronic myeloid leukemia via enrichment analysis of disease-gene network

The potential biological relationship between type‐2 diabetes mellitus (T2DM) has been focused in numerous studies. To investigate the molecular associations among T2DM, prostate cancer (PCa), and chronic myeloid leukemia (CML), using a biomolecular network enrichment analysis. We obtained a list of disease‐related genes and constructed disease networks. Then, GO enrichment analysis was performed to identify the significant functions and pathways of overlapping modules in the Database for Annotation, Visualization and Integrated Discovery (DAVID) database. More than 75% of these overlapping genes were found to be consistent with the findings of previous studies. In the three diseases, we found that Sarcoglycan delta (SGCD) and Rho family GTPase 3 (RND3) were the overlapping genes and identified negative regulation of apoptotic process and negative regulation of transcription from RNA polymerase II promoter RNA as the two overlapping biological functions. CML and PCa were the most closely related, with 34 overlapping genes, five overlapping modules, 27 overlapping biological functions, and nine overlapping pathways. There were 13 overlapping genes, one overlapping modules, four overlapping biological functions and one overlapping pathway (FoxO signaling pathway) were found in T2DM and CML.And T2DM and PCa were the least related pair in our study, with only six overlapping genes, five overlapping modules, and one overlapping biological function. SGCD and RND3 were the main gene‐to‐gene relationship among T2DM, CML, and PCa; apoptosis, development, and transcription from RNA polymerase II promote processes were the main functional connections among T2DM, CML, and PCa by network enrichment analysis. There is a “scalene” relationship among T2DM, CML, and PCa at gene, pathway, biological process, and module levels: CML and PCa were the most closely related, the second were T2DM and PCa, and T2DM and PCa were the least related pair in our study. Our study provides a new avenue for further studies on T2DM and cancers, which may promote the discovery and development of novel therapeutic and can be used to treat multiple diseases.

Impact of prostate cancer radiotherapy on the biological behavior and specific mortality of subsequent bladder cancer

BACKGROUND

The impact of different radiotherapy modalities on the development and characteristics of second primary bladder cancers (BCa) and BCa-specific mortality (BCa-SM) remains unclear. Thus, we evaluated the incidence and biological behavior of subsequent BCa and related survival in patients who underwent radiation therapy for prostate cancer (PCa).

METHODS

A total of 530,581 patients in the surveillance, epidemiology, and end results database with localized PCa between 1988 and 2013 were identified. PCa treatments included radical prostatectomy (RP), external beam radiotherapy (EBRT), radioactive implants (RI), and combined EBRT and RI (EBRI). A multivariable competing risk analysis based on a proportional sub distribution hazards model was used to determine the impact of different radiotherapy modalities on BCa incidence and specific mortality.

RESULTS

Incidence of BCa was significantly high in patients treated with EBRT, RI, and EBRI vs. RP [sub distribution hazard ratio (SHR) 1.41, P < 0.001; SHR 1.58, P < 0.001; SHR 1.56, P < 0.001, respectively]. BCa following EBRT, RI, and EBRI were more commonly non-urothelial (3.3%, 2.9%, 3.3%, respectively, versus 1.2%) and T4 (3.5%, 6.1%, 5.0%, respectively, versus 1.6%) compared with RP. RI associated with a higher rate of BCa metastasis than RP (2.6% vs. 1.1%). Prior EBRT, RI, and EBRI increased BCa-SM (SHR 1.44, P = 0.001; SHR 1.21, P = 0.047; and SHR 1.42, P = 0.032, respectively).

CONCLUSIONS

Patients receiving radiotherapy for PCa have a higher risk of BCa. BCa after EBRT, RI, and EBRI is more likely to be non-urothelial, stage T4, and with increased BCa-SM. Prior RI associated with a higher rate of BCa metastasis.

Second primary malignancy in patients with cholangiocarcinoma: a population-based study

Background

A population-based estimate of risk of second primary malignancy (SPM) in patients with cholangiocarcinoma (CCA) is still lacking.

Objectives

To investigate the overall and site-specific risk of SPM in patients with CCA. To identify risk factors of SPM and further evaluate the impact of SPM on overall survival (OS) and disease specific survival (DSS) in patients with CCA.

Methods

Patients with histologically diagnosed CCA between 1973 and 2015 were identified from the Surveillance, Epidemiology and End Results database. Standardized incidence ratio (SIR) was calculated. Risk factors for SPM and CCA survival were evaluated by logistic, Cox, and nomogram methods.

Results

We found that the overall risk of SPM in patients with CCA was significantly higher than that in the general population (SIR =1.27, 95% CI =1.03–1.55, P<0.05). The risk of SPM was significantly increased at specific sites, including transverse colon, intrahepatic bile duct, other biliary, and thyroid. A significant increase in overall risk was characterized in the subgroups of patients aged ≤29, patients aged 30–59 years, females, whites, and patients with latency ≤11 months (63.41, 2.45, 1.4, 1.3, and 2.6-fold, respectively). In patients with CCA, not having undergone surgery for the first primary malignancy (vs having undergone surgery for the first primary malignancy; HR =0.269; 95% CI =0.211–0.342; P<0.001) was associated with significantly decreased risk of SPM. Patients with SPM had better OS and DSS than those without SPM (Log rank P<0.001). Absence of SPM was an independent risk factor for poorer OS and DSS.

Conclusion

Although the risk of SPM in patients with CCA was significantly increased, the presence of SPM did not shorten OS and DSS of patients with CCA, possibly due to the relatively poorer survival of patients with CCA.

High prevalence of secondary bladder cancer in men on radiotherapy for prostate cancer: evidence from a meta-analysis

Objective

To assess whether radiotherapy (RT) for prostate cancer (PCa) was a risk factor for secondary bladder cancer (BLCa) through a meta-analysis.

Materials and methods

The MEDLINE, Embase, and the Cochrane Library were systematically searched for all studies investigating the risk of BLCa in patients with RT. The association between RT and risk of BLCa was summarized using hazard ratio with a 95%CI. The protocol for this meta-analysis is available from PROSPERO (CRD42018090075).

Results

Overall, 619,479 participants (age: 57-79 years) were included from 15 studies, 206,852 of whom were patients who received RT. Synthesis of results indicated that RT was significantly associated with an increased risk of BLCa compared with the risk in those who received radical prostatectomy or non-RT (overall HR=1.6, 95%CI: 1.33-1.92, P<0.001). The results were consistent when restricted to a 5-year lag period (HR=1.84, 95%CI: 1.26-2.69, P=0.002) and multivariable adjustment (HR=1.96, 95%CI: 1.47-2.62, P<0.001), but not for 10-year lag period (HR=1.93, 95%CI: 0.9- 4.16, P=0.093) and brachytherapy subgroup (HR=1.33, 95%CI: 0.87-2.05, P=0.188). The GRADE-profiler revealed that the rate of events of BLCa on average in the RT-patients and the non-RT control was 2,462/183,669 (1.3%) and 4,263/382,761(1.1%), respectively; the overall quality of the evidence was low.

Conclusion

Patients who received RT for PCa was associated with higher risks of developing secondary BLCa compared to those unexposed to RT, but the absolute effect was low.

Proton therapy for prostate cancer: A review of the rationale, evidence, and current state

Men diagnosed with localized prostate cancer have many curative treatment options including several different radiotherapeutic approaches. Proton radiation is one such radiation treatment modality and, due to its unique physical properties, offers the appealing potential of reduced side effects without sacrificing cancer control. In this review, we examine the intriguing dosimetric rationale and theoretical benefit of proton radiation for prostate cancer and highlight the results of preclinical modeling studies. We then discuss the current state of the clinical evidence for proton efficacy and toxicity, derived from both large claim-based datasets and prospective patient-reported data. The result is that the data are mixed, and clinical equipoise persists in this area. We place these studies into context by summarizing the economics of proton therapy and the changing practice patterns of prostate proton irradiation. Finally, we await the results of a large prospective randomized clinical trial currently accruing and also a large prospective pragmatic comparative study which will provide more rigorous evidence regarding the clinical and comparative effectiveness of proton therapy for prostate cancer.

The impact of pre-existing cancer on survival of prostate cancer patients: A population-based study

Prostate cancer (PCa) is the second most common malignant tumors for male patients worldwide. However, whether a history of pre-existing cancer cases may affect the survival of prostate cancer patients is still not fully understood.We identified patients diagnosed with PCa between 2000 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) linked database. We further made propensity score matching and then compared all-cause and cancer-specific survival between patients with and those without a pre-existing cancer. Cox proportional hazards models and Kaplan-Meier analysis were used for survival comparison.A total of 153,255 patients with PCa were included for analysis, of whom 5939 had a history of pre-existing cancer, including hematologic and lymph (11%), intestine (19%), urinary system (36%), head and neck (9%), lung (5%), skin (12%), and others (8%). Patients with a pre-existing cancer had a worse prognosis compared with those without a pre-existing cancer [all-cause death: hazard ratio (HR) = 2.74, P < .001; cancer-special death: HR = 3.98, P < .001]. Importantly, cancers in urinary bladder prior to PCa had a most adverse impact on all-cause (HR = 5.00, P < .001) and cancer-specific death risk (HR = 10.45, P < .001). Time between the pre-existing cancer and PCa had a dose-dependent effect on survival of PCa patients, with a decreased death risk as the increase of the interval time.Pre-existing cancer has a negative impact on the prognosis of patients with PCa, which is most evident in the presence of a pre-existing urinary bladder cancer. Our results provide epidemiologic evidence with low between-group bias, large sample size, and long-term follow-up, highlighting the need for site-, and interval-time-based clinical management for patients with PCa who had a pre-existing cancer.

External Beam Radiotherapy Increases the Risk of Bladder Cancer When Compared with Radical Prostatectomy in Patients Affected by Prostate Cancer: A Population-based Analysis

BACKGROUND

Long-term survival can be achieved in patients affected by localized prostate cancer (PCa) treated with either radical prostatectomy (RP) or external beam radiotherapy (EBRT). However, development of a second primary tumor is still poorly investigated.

OBJECTIVE

To investigate the impact of RP and EBRT on subsequent risk of developing bladder (BCa) and/or rectal cancer (RCa) among PCa survivors.

DESIGN, SETTING, AND PARTICIPANTS

A total of 84397 patients diagnosed with localized PCa, treated with RP or EBRT between 1988 and 2009, and older than 65 yr of age were identified in the Surveillance, Epidemiology, and End Results Medicare insurance program-linked database. Our primary objective was to investigate the effect of EBRT and RP on the second primary BCa and RCa incidence.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable competing-risk regression analyses were performed to assess the risk of developing a second primary BCa or RCa.

RESULTS AND LIMITATIONS

Of the 84397 individuals included in the study, 33252 (39%) were treated with RP and 51145 (61%) with EBRT. Median follow-up was 69 months, and follow-up periods for patients who did not develop BCa, RCa, or pelvic cancer were 68, 69, and 68 mo, respectively. A total of 1660 individuals developed pelvic tumors (1236 BCa and 432 RCa). The 5- and 10-yr cumulative BCa incidence rates were 0.75% (95% confidence interval [CI]: 0.64-0.85%) and 1.63% (95% CI: 1.45-1.80%) versus 1.26% (95% CI: 1.15-1.37%) and 2.34% (95% CI: 2.16-2.53%) for patients treated with RP versus EBRT, respectively. The 5- and 10-yr cumulative RCa incidence rates were 0.32% (95% CI: 0.25-0.39%) and 0.73% (95% CI: 0.61-0.85%) versus 0.36% (95% CI: 0.30-0.41%) and 0.69% (95% CI: 0.60-0.79%) for patients treated with RP versus EBRT, respectively. On multivariable competing risk regression analyses, treatment with EBRT was independently associated with the risk of developing a second primary BCa (hazard ratio: 1.35, CI: 1.18-1.55; p<0.001), but not RCa (p=0.4). Limitations include lack of information regarding the dose of radiotherapy and the retrospective nature with the implicit risk of selection bias.

CONCLUSIONS

Patients treated with EBRT are at increased risk of developing a second primary BCa compared with those treated with RP. However, no differences were found considering RCa incidence in patients treated with RP or EBRT within the first 5 yr after primary therapy. These results need to be validated in a well-designed randomized prospective trial.

PATIENT SUMMARY

We retrospectively analyzed the risk of developing a second primary bladder or rectal cancer during follow-up for patients treated with radical prostatectomy or external beam radiotherapy for a localized prostate cancer. We found that those treated with external beam radiotherapy are at an increased risk of developing a second primary bladder cancer tumor.

Prostate cancer survivors: Risk and mortality in second primary cancers

To assess etiological and clinical consequences of second primary cancers (SPCs) in prostate cancer (PC) patients, we followed newly diagnosed patients to identify men who were diagnosed with a SPC and recorded their causes of death. We used the Swedish Family‐Cancer Database to assess relative risks (RRs) and causes of death in SPCs until the year 2015 in patients with a PC diagnosis between 2001 and 2010. Among a total of 4.26 million men, 76 614 were diagnosed with PC at the median age of 71 years. Among them, 8659 (11.3%) received a subsequent diagnosis of SPC after a median follow‐up of 4 years. The most common SPCs were colorectal, skin, bladder, and lung cancers, melanoma, and non‐Hodgkin lymphoma. The ranking was almost identical with first cancers among elderly men in Sweden. The RR for SPCs in prostate‐specific antigen—detected PC was approximately equal to RR in other PC. Mortality patterns of PC patients were distinct depending on the presence or absence of SPC. Among patients with SPC, 47.8% died as a result of the corresponding SPC, followed by other causes (22.2%) and PC (18.1%). For patients without SPC, PC and non‐neoplastic causes almost matched each other as the main causes of death (48.5% and 47.8%). The results suggest that SPCs appear autonomous from primary PC and reflect incidence and mortality of first cancers in general. SPC was the most common cause of death in patients with SPC; close to half of the patients died due to SPC. For improved survival in PC patients, prevention and early detection of SPCs would be important, and the present results suggest that risk factors for SPC in PC are the same as those for first cancer in general.

The impact of age at the time of radiotherapy for localized prostate cancer on the development of second primary malignancies

PURPOSE

There is a known increased risk of second primary malignancy (SPM) in patients with prostate cancer (CaP) treated with radiotherapy (RT). It is unclear how age at diagnosis influences the risk of SPMs.

MATERIALS AND METHODS

Using the 1973 to 2013 Surveillance, Epidemiology, and End Results Program, we studied the impact of age on SPMs (defined as a bladder or rectal tumor) after localized CaP treatment with radical prostatectomy (RP) or RT. SPM risk was compared using inverse probability of treatment weighting (IPTW)-adjusted cumulative incidence function and competing-risk proportional hazard models. Overall survival (OS) in patients with SPM was compared using Kaplan Meier and Cox regression analyses.

RESULTS

A total of 579,608 patients met inclusion criteria, and 51.8% of the cohort was treated with RT. The 10- and 20-year cumulative incidences of competing risk (IPTW adjusted) of SPMs were 1.9% (95%CI = 1.8-1.9%) and 3.6% (95%CI = 3.4-3.7%) after RP vs. 2.7% (95%CI = 2.6-2.8%) and 5.4%(95%CI = 5.3-5.6%) after RT. IPTW-adjusted competing risk hazard ratio (HR) of SPM after RT compared to RP was increased in the entire cohort (HR 1.46; 95%CI = 1.39-1.53, P < 0.001) and was highest in the youngest patients: Age <55 HR = 1.83 (95% confidence interval [CI] = 1.49-2.24, P<0.001), Age 55 to 64 HR = 1.66 (95%CI = 1.54-1.79, P < 0.001), Age 65-74 HR = 1.41 (95%CI = 1.33-1.48, P < 0.001), Age ≥75 HR = 1.14 (95%CI = 0.97-1.35, P = 0.112). At 10 years, SPM-specific mortality occurred in 28.9% of patients treated with RT, though OS with SPM was worse in the youngest patients: Age <55 HR = 1.88 (95%CI = 1.25-2.81, P = 0.002), Age 55-64 HR = 1.60 (95%CI = 1.42-1.81, P < 0.001), Age 65-74 HR = 1.40 (95%CI = 1.30-1.52, P < 0.001), Age ≥ 75 HR = 1.27 (95%CI = 1.06-1.53, P = 0.009). All of the age categories had similar median follow-up times.

CONCLUSION

At 10 years there is a 1.8% increased incidence of SPM after RT compared to RP, of which <30% of RT-treated patients with an SPM die as a result of a SPM. However, the risk of SPMs was greatest among younger men treated with RT for localized CaP, and this relationship could not be explained solely by follow-up time, latency time, or life expectancy. An improved understanding of those at the highest risk of SPMs may help tailor treatment and surveillance strategies.

Risk of secondary rectal cancer and colon cancer after radiotherapy for prostate cancer: a meta-analysis

PURPOSE

To investigate whether radiotherapy for prostate cancer increases the risk of therapy-related rectal cancer and colon cancer.

METHODS

A systematic literature search was carried out using the Medline (PubMed), EMBASE, and the Cochrane Library to identify studies examining the association between radiotherapy for prostate cancer and secondary colorectal cancer (rectal cancer and colon cancer) published before March 19, 2018. The risk of second colorectal cancer after radiotherapy was summarized using unadjusted odds ratio (OR) and adjusted hazard ratio (HR) with their 95% confidence interval (CI). Subgroup and sensitivity analyses were conducted to detect potential bias and heterogeneity.

RESULTS

After study selection, 16 reports were retrieved for analysis. When patients received radiotherapy compared with those unexposed to radiation, there was an increased risk of the rectal cancer (OR 1.37, 95%CI 1.01 to 1.85), but not colon cancer. According to adjusted HR, there was an increased risk of the rectal cancer (HR 1.64, 95%CI 1.39 to 1.94), and colon cancer (HR 1.33, 95%CI 1.02 to 1.76). The OR for rectal cancer showed an increased risk with longer latent period (5 years lag time versus 10 years lag time, OR: 1.56 versus 2.22). Brachytherapy had no association with second cancer across all analyses.

CONCLUSIONS

Radiotherapy was associated with an increased risk of subsequent rectal cancer compared with patients unexposed to radiation. Colon may be free from the damage of radiation. Brachytherapy had no association with second rectal cancer or colon cancer.

Androgen deprivation therapy is associated with decreased second primary lung cancer risk in the United States veterans with prostate cancer

OBJECTIVES

We investigated whether androgen deprivation therapy (ADT) in prostate cancer patients was associated with a decreased risk for second primary lung cancer in US veterans.

METHODS

Prostate cancer diagnoses in the US Veterans Affairs Cancer Registry between 1999 and 2008 were identified. Use of hormonal therapy and diagnoses of second primary lung cancer were determined from the registry. Synchronous prostate and lung cancers, defined as 2 diagnoses made within 1 year, were excluded from the analysis. Cancer-free survival was estimated using the Kaplan-Meier method and hazard ratios were estimated using Cox proportional hazard models.

RESULTS

Among the 63,141 identified patients with prostate cancer, 18,707 subjects were eligible for the study. Hormonal therapy was used in 38% of patients and the median follow-up period was 28 months. ADT use was associated with longer lung cancer-free survival in prostate cancer patients (log-rank p=0.01). After adjusting for age, race, smoking and prostate cancer stage, ADT use was associated with decreased lung cancer risk by 15, 21, and 24% after 1, 2, and 3 years, respectively.

CONCLUSIONS

ADT in prostate cancer patients may be associated with decreased second primary lung cancer risk among US veterans.

Excessive risk of second primary cancers in young-onset colorectal cancer survivors

With an increasing trend of patients with young-onset colorectal cancer (CRC), risks of second primary cancers (SPCs) among them become a concerning issue. We aimed to define the detailed risk and site-distributed patterns of SPCs in young CRC individuals (age ≤50). A population-based cohort were identified from the Surveillance, Epidemiology, and End Results database between 1973 and 2013. Standardized incidence ratios (SIRs) and absolute excess risk (AER) were calculated to assess the risk for SPCs compared with the general population. A total of 44,106 patients, including 3245 (7.4%) the young and 40,861 (92.6%) the old, developed 50,679 secondary malignancies subsequently. With increased age, the risk of secondary cancers gradually decreased. A significant 44% excess risk of SPCs was observed in the young (SIR = 1.44, AER = 34.23), while a slightly increased risk was noted in the old (SIR = 1.02, AER = 4.29). For young survivors, the small intestine (SIR = 8.49), bile ducts (SIR = 3.77), corpus, and uterus (SIR = 2.45) were the most common sites of SPCs. Significantly, excess SIRs in the young were persisted regardless of other factors. For the young, secondary cancer-related deaths were responsible for 51.2% of overall deaths and secondary stomach, liver and bile, pancreas cancers were top three causes. An excessive risk of SPCs existed in young CRC survivors, and this trend was consistent among different subgroups. We hope our findings may inform future targeted screening strategies among young-onset CRC survivors.

Second primary malignancy after radical prostatectomy in a cohort from the Middle East

Background

Data from the Middle East regarding second primary malignancy (SPM) after radical prostatectomy are limited. Our objective was to estimate the overall risk of developing second primary malignancy (SPM) among Middle Eastern men with prostate cancer who underwent surgical extirpation of their prostate.

Materials and methods

We conducted a retrospective study of 406 patients who underwent radical prostatectomy in a tertiary centre and who had no evidence of previous malignancy from 1998 to 2012. Standardized incidence ratios (SIRs) and 95% confidence interval (CI) were calculated to analyze the risk of SPM in our population compared with the general population. Cox-regression models were also conducted to correlate the clinicopathological factors with the development of SPM.

Results

After 14 years of follow-up, the incidence rate of SPM was 100.9 per 1,000 person-years. The most frequent SPMs were bladder cancer (n = 11, 27%) followed by hematological malignancies (n = 9, 22%) and lung cancer (n = 7, 17%). The overall risk for men with prostate cancer to develop SPM is lower than the men in the general population (standardized incidence ratios = 0.19; 95% CI: 0.14–0.25). A multivariate analysis failed to correlate any of the clinicopathological factors with the development of SPM.

Conclusion

Patients with prostate cancer who underwent surgical expiration of their prostate are at lower risk of developing SPM compared with the general population.

Descriptive characteristics of prostate cancer in patients with a history of primary male breast cancer - a SEER analysis

Background

Current evidence on risk of prostate cancer following a diagnosis of male breast cancer is limited and guidance for screening in this potentially higher-risk population remainsunclear. Our objective was to quantify prostate cancer risk in men diagnosed with breast cancer.

Methods

We identified men diagnosed with first primary breast cancer between 1988 and 2012 using the Surveillance, Epidemiology and End Results Program registry databases. Men were followed for occurrence of a second primary prostate cancer and secondary outcomes of cancer-specific and overall survival. Stratified analyses were performed by age, breast cancer stage, race, and breast cancer hormone receptor status. Excess risk per 10,000 person-years and standardized incidence ratios (SIR) with 95% confidence intervals (95% CI) were calculated. We used multivaraible Cox proportional hazard models to estimate hazard ratios (HR) and 95% CI for characteristics associated with secondary prostate cancer and survival.

Results

From a cohort of 5753 men with breast cancer with median follow up of 4.3 years, we identified 250 cases of second primary prostate cancer. Overall, the incidence of second primary prostate cancer was modestly greater than expected (SIR = 1.12, 95% CI 0.93–1.33), although not statistically significant. Stratified analyses demonstrated associations for men ages 65–74 at the time of breast cancer diagnosis (SIR = 1.34, 95%CI 1.01–1.73), hormone receptor-positive breast cancer (SIR = 1.23, 95%CI 1.11–1.39) or AJCC stage I breast cancer (SIR = 1.36, 95%CI 1.04–1.75) and second primary prostate cancer diagnosis.

Conclusions

The incidence of prostate cancer in men with history of breast cancer is similar to the general population. Men with favorable characteristics of their breast cancer were more likely to develop prostate cancer, possibly due to a lower competing risk of breast cancer mortality.

The influence of inter-fractional anatomy variation on secondary cancer risk estimates following radiotherapy

PURPOSE

In silico studies comparing estimated risks of radiation-induced secondary cancer (SC) are frequently performed in assessment of radiotherapy techniques. Since inter-patient anatomy variations can result in considerable differences in estimated risk we aimed to explore the influence of inter-fractional organ motion patterns on SC risk.

METHODS

Volumetric modulated arc therapy (VMAT) and intensity-modulated proton therapy (IMPT) plans were generated on the planning CT (pCT) scans of eight prostate cancer patients. In addition, the treatment plans were re-calculated on 8-9 repeat CTs (rCTs) of each patient acquired throughout the treatment course. Relative risk (RR) of SC (VMAT/IMPT) was calculated for the planned and the re-calculated dose distributions using the organ equivalent dose concept adapted to a linear and a bell-shaped competition dose-response model.

RESULTS

Day-to-day variations in anatomy lead to fluctuations in SC risk estimates of the same order of magnitude as those caused by inter-patient variations. Using the competition model, the RR range for bladder cancer based on the pCTs was 0.4-3.4, while a considerably wider range was found when including all rCTs (0.2-6.7). There was nevertheless a correlation in RR based on repeat CTs for individual patients, indicating that patient-specific SC risks could be estimated.

CONCLUSIONS

The estimated relative risks varied considerably across rCTs and could change the risk in favour of VMAT/IMPT depending on the anatomy of the day. The results demonstrate the importance of performing in silico studies of SC risk on a cohort of patients or multiple CTs when structures subject to organ motion are involved.

Risk of second primary malignancies among patients with prostate cancer: A population-based cohort study

Purpose

The rising incidence and life expectancy associated with prostate cancer (PCa) has led to increasing interest in predicting the risk of second primary malignancies (SPMs) among PCa survivors, although data regarding SPMs after PCa are controversial.

Methods

We identified 30,964 patients from the National Health Insurance Research Database in Taiwan who had newly diagnosed PCa between 2000 and 2010. Each patient was randomly frequency-matched with an individual without PCa, based on age, comorbidity, and index year. Competing-risks regression models were used to estimate subhazard ratios (SHRs) of SPMs development associated with PCa. The Bonferroni adjustment was used in multiple comparisons.

Results

Men with PCa had a trend of lower risk of developing overall SPMs compared to those without PCa (adjusted SHR = 0.94, 99.72% confidence interval [CI] = 0.89–1.00, p = 0.06). The risks of lung and liver cancer were significantly lower. In contrast, these patients had a significantly higher risk of thyroid cancer. There is a trend for a higher risk of developing SPMs in the urinary bladder and rectum/anus. Further analyses indicated that PCa patients who received radiation therapy (RT) had an increased risk of overall SPMs, hematologic malignancies, esophageal cancer, liver cancer, lung cancer, and urinary bladder cancer compared with those who did not receive RT.

Conclusion

Men with PCa tended to have a lower risk of SPMs, but a significantly higher risk of subsequent thyroid cancer. Continued cancer surveillance is required among PCa survivors, especially in specific sites and in individuals who received RT.

Risk of subsequent primary malignancies among patients with prior colorectal cancer: a population-based cohort study

BACKGROUND

The site-distribution pattern and relative risk of subsequent primary malignancies (SPMs) in colorectal cancer (CRC) patients remains to be determined.

MATERIALS AND METHODS

A population-based cohort of 288,390 CRC patients diagnosed between 1973 and 2012 from the Surveillance, Epidemiology, and End Results database was retrospectively reviewed. Standardized incidence ratios were calculated to estimate the relative risk for SPMs.

RESULTS

The overall risk of SPMs increased in CRC patients (standardized incidence ratio 1.02) in the first 5 years after CRC diagnosis compared with that in the general population, and was negatively related to age at diagnosis. Risk increased significantly for cancers of the small intestine, ureter, colorectum, renal pelvis, endocrine system, and stomach, and decreased significantly for cancers of the gallbladder, liver, myeloma, and brain, as well as lymphoma. Patients with different prior CRC subsites showed specific sites at high risk of SPM. Prior right-sided colon cancer was associated with cancers of the small intestine, ureter, renal pelvis, thyroid, stomach, pancreas, and breast and prior left-sided colon cancer associated with secondary CRC, whereas rectal cancer was associated with cancers of the vagina, urinary bladder, and lung.

CONCLUSION

Risk of SPMs increases in CRC survivors, especially in the first 5 years after prior diagnosis. Intensive surveillance should be advocated among young patients, with specific attention to the small intestine, colorectum, renal pelvis, and ureter. The common sites at high risk of SPM originate from the embryonic endoderm. Genetic susceptibility may act as the main mechanism underlying the risk of multiple cancers.

Non-Small Cell Lung Cancer as a Second Primary Among Patients With Previous Malignancy: Who Is at Risk?

BACKGROUND

Patients with previous malignancies could be at increased risk of non-small cell lung cancer (NSCLC). However, the extent of the risk is unknown for many cancer types; thus, it is unclear who might benefit from screening.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results data set from 1992 to 2012 was used to identify patients with previous malignancies who received a diagnosis of NSCLC ≥ 6 months after their initial cancer diagnosis. Standardized incidence ratios (SIRs) for NSCLC were calculated as a ratio of the observed to expected cases adjusted by person-years at risk. Cancers with a SIR > 1.0 had a risk of NSCLC greater than expected. The analyses were stratified by sex, radiation therapy use, and histologic type.

RESULTS

Among the cancer survivors, 32,058 developed NSCLC. Smoking-related (lung, head and neck, bladder) and hematologic malignancies, regardless of previous radiation therapy, had the greatest SIR for NSCLC (range, 1.97-4.88). Colorectal and renal cancer survivors also had an increased SIR for NSCLC (1.16 and 1.21, respectively). Women with previous pancreatic cancer treated with radiation, breast cancer with or without radiation therapy, and those with thyroid cancer demonstrated a greater SIR for lung adenocarcinoma. Men with previous irradiated prostate cancer also had an elevated SIR (1.08; 99% confidence interval, 1.01-1.15) for lung adenocarcinoma. Patients with melanoma, prostate or uterine cancer had a lower SIR for NSCLC than expected.

CONCLUSION

Smoking-related malignancies had the greatest risk of NSCLC. Radiation therapy conferred an elevated risk of NSCLC for certain cancers. Melanoma, prostate, and uterine cancer survivors had a low risk of NSCLC. These results could help identify high-risk screening candidates in the growing population of cancer survivors.

Prostate cancer survivorship: Implementation of survivorship care plans to meet the mandate and enhance urologic practice through collaborative care

Prostate cancer is the most common malignancy among the male survivorship population in the United States, representing 44% of approximately 7 million survivors. In the era of modern medicine and value-based care, successfully treating only the cancer is not sufficient. The cancer survivor represents an individual in need of restoration and protection against future events. A well-designed and well-supported survivorship program not only meets a mandate for accreditation, it logically translates into better patient care. This review summarizes the history of the survivorship movement, outlines some key elements of a survivorship program, and highlights the opportunity to apply these principles to improve cancer-related care, develop relationships with colleagues that may allow increased identification of men at risk, and expand both the experience and outcomes of individual specialists within men's health.

Risk of second cancer following radiotherapy for prostate cancer: a population-based analysis

Background

To investigate the risk of second cancer and radiation induced second cancer following prostate cancer radiotherapy.

Methods

We compared men with radiotherapy only with those treated with radical prostatectomy only and those with radiotherapy after radical prostatectomy. Cumulative incidences of second cancers were calculated. Cox analyses were performed to identify determinants influencing second cancer incidence.

Results

Nineteen thousand five hundred thirty eight patients were analyzed. Age and median follow-up differed significantly with radiotherapy only patients having the highest median age (70.3 years) and radical prostatectomy only patients the longest median follow-up (10.2 years). Ten-year cumulative incidence of second cancer was 15.9%, 13.2% and 10.5% for patients with radiotherapy only, radiotherapy after radical prostatectomy and radical prostatectomy only (p <0.0001). Increasing age and belonging to the radiotherapy only group were associated with a higher risk of second cancer—no significant increase was seen in radiotherapy after radical prostatectomy patients. A significantly higher rate of smoking related malignancies, like lung, bladder and non-melanoma skin cancer, was seen in radiotherapy only patients.

Conclusions

No clear increase in radiation induced second cancer was found in patients after radiotherapy for prostate cancer. Whereas the rate of second cancer was increased in radiotherapy only patients, no such increase was seen in patients with radiotherapy after radical prostatectomy. The increase of second cancer following radiotherapy only is highly likely to reflect advanced age and lifestyle habits and comorbidities.

Radical prostatectomy in Denmark: Survival analysis and temporal trends in clinicopathological parameters with up to 20 years of follow-up

OBJECTIVES

To describe mortality, cause of death, and temporal trends in clinicopathological parameters with up to 20 years of follow-up in a nationwide cohort of prostate cancer (PCa) patients who underwent radical prostatectomy (RP).

MATERIALS AND METHODS

A total of 6857 patients with PCa treated with RP at six different hospitals in Denmark between 1995 and 2011. Data were extracted from the nationwide DaPCa database. Histopathology reports from the RP specimens were manually reviewed. Date and cause of death were obtained from national registries and cross-checked in patient files. The cumulative incidence of PCa specific mortality (PCSM) was analysed with the Aalen-Johansen method for competing risks with non-PCa death as a competing event. Risk of PCSM was analysed in a multivariate Cox regression model using age, preoperative PSA level, surgical margin status, RP Gleason score (GS), pathological T-category, and N-category as explanatory variables.

RESULTS

The median follow-up was 6.4 years. Significant temporal changes in clinicopathological parameters were observed. During the study period, median age at surgery increased from 61.4 to 64.8 years and median preoperative PSA declined from 12.0 to 8.0 ng/ml. The proportion of men with pT2 PCa increased from 65% to 75% whereas the proportion of pT3 cancers decreased from 28% to 25%. The percentage of men with positive surgical margins decreased from 37% to 20%. During follow-up, 644 patients died, whereof 189 (29.3%) died from PCa. The cumulative incidence of PCSM and other-cause mortality after 15 years was 10.3% (95% CI 8.0-12.7) and 18.2% (95% CI 15.4-20.9), respectively. In a multivariate analysis, RP GS (P ≤ 0.001) and pT-category (P ≤ 0.001) were significantly associated with the risk of PCSM. Compared with GS ≤6, both GS +4 (HR 1.47), GS 4 + 3 (HR 2.32), GS 8 (HR 4.8) and GS 9 or 10 (HR 5.26) significantly increased the risk of PCa death. T3a PCa and T3b/T4 was also a significant predictor of PCSM with an increased risk of PCa death compared with pT2 of 2.24 and 4.5, respectively.

CONCLUSIONS

In a complete national cohort of men treated with RP during a 17-year period, we described the incidence of mortality after RP and predictors of PCSM. We demonstrated that RP GS and pT-category are the most significant predictors of PCa mortality. We found that an increasing proportion of men undergo RP for low-risk PCa suggesting that early detection of PCa is indeed undergoing in Denmark despite national recommendations. The Danish national results seem to concur with findings from international single- and multi-institutional reports.

Cause of Death in Korean Men with Prostate Cancer: an Analysis of Time Trends in a Nationwide Cohort

Despite rapid increase in incidence of prostate cancer (PC) and PC survivors, there are few studies regarding competing causes of death and time trends in Asian population. We conducted a cohort study of 2% nationwide random sample of Korean National Health Insurance employees. A total of 873 patients who had received active treatments, including surgery, radiation therapy (RT) and androgen deprivation therapy (ADT), for newly diagnosed PC between 2003 and 2010 were included. The cause of death was categorized as PC, other cancers, cardiovascular disease, and other causes. During a median follow-up of 4.75 years, 29.4% (257/873) of the study population died. PC, other cancers, cardiovascular disease, and other causes were responsible for 46.3%, 35.4%, 6.6%, and 11.7%, respectively, of the decedents. Significant differences existed in the cause of death among treatment groups (P < 0.001). Only 20% and 9.5% of surgery and RT group died of PC, whereas 63.9% of ADT group died of PC. Other cancers were responsible for 56%, 74.6% and 17.8% of death in the surgery, RT and ADT group, respectively, while cardiovascular disease accounted for 4%, 6.3%, and 7.1% of death in the treatment groups. Analysis of time trends showed that PC-specific death tended to decrease (from 42.9% in 2003 to 23.1% in 2010), whereas non-PC causes tended to increase over the 8 years. Our results are valuable in overviewing causes of death and time trends in Korean PC patients, and planning future health policy for PC.

Is there a role for IGF-1 in the development of second primary cancers?

Cancer survival rates are increasing, and as a result, more cancer survivors are exposed to the risk of developing a second primary cancer (SPC). It has been hypothesized that one of the underlying mechanisms for this risk could be mediated by variations in insulin-like growth factor-1 (IGF-1). This review summarizes the current epidemiological evidence to identify whether IGF-1 plays a role in the development of SPCs. IGF-1 is known to promote cancer development by inhibiting apoptosis and stimulating cell proliferation. Epidemiological studies have reported a positive association between circulating IGF-1 levels and various primary cancers, such as breast, colorectal, and prostate cancer. The role of IGF-1 in increasing SPC risk has been explored less. Nonetheless, several experimental studies have observed a deregulation of the IGF-1 pathway, which may explain the association between IGF-1 and SPCs. Thus, measuring serum IGF-1 may serve as a useful marker in assessing the risk of SPCs, and therefore, more translational experimental and epidemiological studies are needed to further disentangle the role of IGF-1 in the development of specific SPCs.

Secondary Cancers After Radiation Therapy for Primary Prostate or Rectal Cancer

Literature about the risk of secondary cancer after radiation therapy (RT) of prostate and rectal cancer reveals contradictory results. We conducted a meta-analysis to examine whether the RT induces secondary rectal or prostate cancer in patients, respectively, with prostate or rectal cancer. All studies published in Medline or Pubmed up to March 3, 2015, containing RT of primary rectal or prostate cancer, and providing risk estimates of secondary prostate or rectal cancer were considered as eligible. Relative risk (RR) and standardized incidence ratios (SIR) were calculated using the random-effects model. Twenty studies met the inclusion criteria. 12 of them were from the Surveillance, Epidemiology, and End Results (SEER) database. For prostate cancer patients, pooled adjusted RRs or SIRs did not show an effect on the risk of secondary rectal cancer. However, notwithstanding the limitations of SEER-based studies, the subgroup of prostate cancer patients receiving external beam radiation therapy (EBRT) showed an increased risk of rectal cancer. For rectal cancer patients, pooled adjusted RR of prostate cancer was 1.12 (95 % CI, 0.44-2.8) and SIR was 0.40 (95 % CI, 0.29-0.55). All studies included in the SIR analysis of rectal cancer were derived from the SEER data source. Based on current evidence, RT for prostate cancer patients had no effect on rectal cancer incidence, except for patients who received EBRT therapy. However, compared with the general population, RT for rectal cancer is associated with a decreased prostate cancer risk as found in SEER-based studies.

Chronic opioid therapy in long-term cancer survivors

PURPOSE

Long-term cancer survivors develop special health issues and specific needs. Chronic pain, whether the consequence of their cancer or as a side effect of treatment, is one of their most prevalent concerns.

METHODS

We conducted a review of the English-language literature on long-term cancer survivorship and chronic opioid therapy, with the objective of determining the efficacy, safety and tolerability in this group of patients. Practical management recommendations are made on the basis of this review.

RESULTS

Pain syndromes encountered in the long-term cancer survivors are diverse. Opioid receptor pathways possess complex and pleiotropic functions and continuous over-activation may lead to de novo endocrinopathies, immunosuppression, neurocognitive impairment, or cell cycle disturbances with potential clinical connotations. However, there are insufficient data to support evidence-based decision making with respect to patient selection, doses, administration, monitoring and follow-up. Data about long-term treatment effectiveness and safety are limited and often aggravated by the overlapping of several diseases prevalent among long-term cancer survivors, as well as chronic opiate-induced toxicity.

CONCLUSIONS

Chronic opioid therapy is frequent in long-term cancer survivors, and may negatively affect the immune system, and produce health problems such as endocrinopathies, osteoporosis, neurological or cardiopulmonary effects, alterations of cell cycle kinetics, abuse and addiction. This review highlights the need for specialized teams to treat chronic pain in long-term cancer survivors from an integrative perspective.

A (relatively) risky business: the link between prostatic radiotherapy and second malignancies

Unlikely to change therapeutic decisions for most men with high grade prostate cancer

Second malignancies after radiotherapy for prostate cancer: systematic review and meta-analysis

OBJECTIVE

To determine the association between exposure to radiotherapy for the treatment of prostate cancer and subsequent second malignancies (second primary cancers).

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

Medline and Embase up to 6 April 2015 with no restrictions on year or language.

STUDY SELECTION

Comparative studies assessing the risk of second malignancies in patients exposed or unexposed to radiotherapy in the course of treatment for prostate cancer were selected by two reviewers independently with any disagreement resolved by consensus.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted study characteristics and outcomes. Risk of bias was assessed with the Newcastle-Ottawa scale. Outcomes were synthesized with random effects models and Mantel-Haenszel weighting. Unadjusted odds ratios and multivariable adjusted hazard ratios, when available, were pooled.

MAIN OUTCOME MEASURES

Second cancers of the bladder, colorectal tract, rectum, lung, and hematologic system.

RESULTS

Of 3056 references retrieved, 21 studies were selected for analysis. Most included studies were large multi-institutional reports but had moderate risk of bias. The most common type of radiotherapy was external beam; 13 studies used patients treated with surgery as controls and eight used patients who did not undergo radiotherapy as controls. The length of follow-up among studies varied. There was increased risk of cancers of the bladder (four studies; adjusted hazard ratio 1.67, 95% confidence interval 1.55 to 1.80), colorectum (three studies; 1.79, 1.34 to 2.38), and rectum (three studies; 1.79, 1.34 to 2.38), but not cancers of the hematologic system (one study; 1.64, 0.90 to 2.99) or lung (two studies; 1.45, 0.70 to 3.01), after radiotherapy compared with the risk in those unexposed to radiotherapy. The odds of a second cancer varied depending on type of radiotherapy: treatment with external beam radiotherapy was consistently associated with increased odds while brachytherapy was not. Among the patients who underwent radiotherapy, from individual studies, the highest absolute rates reported for bladder, colorectal, and rectal cancers were 3.8%, 4.2%, and 1.2%, respectively, while the lowest reported rates were 0.1%, 0.3%, and 0.3%.

CONCLUSION

Radiotherapy for prostate cancer was associated with higher risks of developing second malignancies of the bladder, colon, and rectum compared with patients unexposed to radiotherapy, but the reported absolute rates were low. Further studies with longer follow-up are required to confirm these findings.

Risk of colorectal cancer after the diagnosis of prostate cancer: A population-based study

BACKGROUND

A rigorous assessment of the risk of colorectal cancer (CRC) among prostate cancer (PC) survivors that controls for important confounding factors and competing risks is necessary to determine the risk of CRC in this population and to inform screening guidelines.

METHODS

With data from Manitoba, Canada, subjects diagnosed with PC as their first cancer between 1987 and 2009 were age-matched with up to 5 men with no history of invasive cancer on the PC diagnosis date. Subjects were followed to the date of diagnosis of CRC or another cancer, death, emigration, or the study endpoint (December 31, 2009). Competing risk proportional hazards models were used to compare the CRC incidence between those with PC and those without PC with the following model covariates: history of lower gastrointestinal endoscopy, frequency of health care visits, diabetes, and socioeconomic status. Mutually exclusive competing outcomes included CRC, another primary cancer, and death.

RESULTS

For a total of 559,081 person-years, 14,164 men with PC and 69,051 men without PC were followed. Men diagnosed with PC had an increased risk of a subsequent diagnosis of CRC (all CRC: hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.02-1.27; rectal cancer: HR, 1.36; 95% CI, 1.09-1.71). The treatment of PC with radiation was associated with an increased risk for rectal cancer (HR, 2.06; 95% CI, 1.42-2.99) in comparison with PC cases not treated with radiation.

CONCLUSIONS

The risk of CRC is increased after a diagnosis of PC and is highest for rectal cancer among those treated with radiation. CRC screening should be considered soon after the diagnosis of PC, especially for men planning for radiotherapy.

The Prognostic Value of Previous Irradiation on Survival of Bladder Cancer Patients

Background: Radiation exposure is an established risk factor for bladder cancer, however consensus is lacking on the survival characteristics of bladder cancer patients with a history of radiation therapy (RT). Confounding patient comorbidities and baseline characteristics hinders prior attempts at developing such a consensus.

Objective: To compare the survival characteristics of patients with suspected radiation-induced second primary cancer (RISPC) of the bladder to those with de novo bladder cancer, taking into account the patient comorbidities and baseline characteristics predictive of survival.

Methods: Retrospective analysis of patients with muscle-invasive (≥T2a) or BCG-refractory stage Tis-T1 urothelial bladder cancer. Patients were excluded if prior RT exposure was used as treatment for bladder cancer or if cause of death was due to post-operative complications. A digit matching propensity score algorithm was used to match patients with prior radiation treatment to those without prior treatment. Cox regression analysis for time until death was performed following creation of the propensity score matched sample.

Results: 29 patients with history of RT were matched with two controls each, resulting in a dataset of 87 observations in the event model. Results from the Cox model indicate a significantly increased hazard ratio for death at 2.22 (p = 0.047, 95% CI: 1.015–4.860) given a history of prior radiation therapy.

Conclusions: In a small cohort, bladder cancer patients who underwent cystectomy had a significantly higher risk of death in the face of prior pelvic RT. This effect was found to be independent of surgical complications, numerous established patient characteristics and comorbidities traditionally predictive of survival.

Risk of Second Primary Cancer among Prostate Cancer Patients in Korea: A Population-Based Cohort Study

As patients with prostate cancer have a long life expectancy, there is increasing interest in predicting the risk of development of a second primary cancer (SPC), and we therefore designed this study to estimate the overall risk of developing SPCs among Korean prostate cancer patients. We used a population-based cohort from the Korean Central Cancer Registry composed of 55,378 men diagnosed with a first primary prostate cancer between 1993 and 2011. Standardized incidence ratios (SIRs) of SPCs were analyzed by age at diagnosis, latency period, period of diagnosis, and type of initial treatment. Survival analysis was stratified by development of SPC. Men with primary prostate cancer had an overall lower risk of developing an SPC [SIR = 0.75; 95% CI, 0.72-0.78], which was significant for SPCs of the esophagus, stomach, rectum, liver, gallbladder, bile duct, pancreas, larynx, lung, and bronchus. In contrast, there were significant increases in the risk of bladder and thyroid cancers, which tended to decrease after longer follow-up. Patients who received initial radiation therapy had an increased risk of subsequent rectal cancer, although this was still lower than that of the general male population. Other urinary tract cancers including those of the kidney, renal pelvis, and ureter tended to be associated with a higher risk of developing an SPC, but this difference did not reach statistical significance. The patients with prostate cancer and SPC had lower overall survival rates than those with one primary prostate cancer. Our findings suggest that men with prostate cancer have a 25% lower risk of developing an SPC in Korea, but a higher risk of developing subsequent bladder and thyroid cancers, which suggests the need for continued cancer surveillance among prostate cancer survivors.

Risk of Second Primary Cancer among Prostate Cancer Patients in Korea: A Population-Based Cohort Study

As patients with prostate cancer have a long life expectancy, there is increasing interest in predicting the risk of development of a second primary cancer (SPC), and we therefore designed this study to estimate the overall risk of developing SPCs among Korean prostate cancer patients. We used a population-based cohort from the Korean Central Cancer Registry composed of 55,378 men diagnosed with a first primary prostate cancer between 1993 and 2011. Standardized incidence ratios (SIRs) of SPCs were analyzed by age at diagnosis, latency period, period of diagnosis, and type of initial treatment. Survival analysis was stratified by development of SPC. Men with primary prostate cancer had an overall lower risk of developing an SPC [SIR = 0.75; 95% CI, 0.72-0.78], which was significant for SPCs of the esophagus, stomach, rectum, liver, gallbladder, bile duct, pancreas, larynx, lung, and bronchus. In contrast, there were significant increases in the risk of bladder and thyroid cancers, which tended to decrease after longer follow-up. Patients who received initial radiation therapy had an increased risk of subsequent rectal cancer, although this was still lower than that of the general male population. Other urinary tract cancers including those of the kidney, renal pelvis, and ureter tended to be associated with a higher risk of developing an SPC, but this difference did not reach statistical significance. The patients with prostate cancer and SPC had lower overall survival rates than those with one primary prostate cancer. Our findings suggest that men with prostate cancer have a 25% lower risk of developing an SPC in Korea, but a higher risk of developing subsequent bladder and thyroid cancers, which suggests the need for continued cancer surveillance among prostate cancer survivors.

Risk of radiation-induced secondary rectal and bladder cancer following radiotherapy of prostate cancer

BACKGROUND

An elevated risk of radiation-induced secondary cancer (SC) has been observed in prostate cancer patients after radiotherapy (RT), rising to as high as one in 70 patients with more than 10 years follow-up. In this study we have estimated SC risks following RT with both previous and contemporary techniques, including proton therapy, using risk models based on different dose-response relationships.

MATERIAL AND METHODS

RT plans treating the prostate and seminal vesicles with either conformal radiotherapy (CRT), volumetric modulated arc therapy (VMAT) or intensity-modulated proton therapy (IMPT) were created for 10 patients. The risks of radiation-induced cancer were estimated for the bladder and rectum using dose-response models reflecting varying degrees of cell sterilisation: a linear model, a linear-plateau model and a bell-shaped model also accounting for fractionated RT.

RESULTS

The choice of risk models was found to rank the plans quite differently, with the CRT plans having the lowest SC risk using the bell-shaped model, while resulting in the highest risk applying the linear model. Considering all dose-response scenarios, median relative risks of VMAT versus IMPT were 1.1-1.7 for the bladder and 0.9-1.8 for the rectum. Risks of radiation-induced bladder and rectal cancers were lower from VMAT if exposed at 80 years versus IMPT if exposed at 50 years.

CONCLUSIONS

The SC risk estimations for the bladder and rectum revealed no clear relative relationship between the contemporary techniques and CRT, with divergent results depending on choice of model. However, the SC risks for these organs when using IMPT were lower or comparable to VMAT. SC risks could be assessed when considering referral of prostate cancer patients to proton therapy, taking also general patient characteristics, such as age, into account.

Radiotherapy for high-risk prostate cancer

The combination of radiation treatment and long-term androgen deprivation therapy (ADT) has been shown in multiple clinical trials to prolong overall survival in men with high-risk prostate cancer compared with either treatment alone. New radiation technologies enable the safe delivery of high radiation doses that improve cancer control compared with lower radiation doses. Based on the results of multiple randomized trials, clinical practice guidelines for high-risk prostate cancer recommend total radiation doses of at least 75.6 Gy, with long-term (2-3 years) ADT. Ongoing research into hypofractionated radiation treatment, whole-pelvic radiation, and combinations of radiation with novel hormonal agents could further improve cancer control and survival outcomes for patients with high-risk prostate cancer.

Prostate cancer survivorship care guideline: American Society of Clinical Oncology Clinical Practice Guideline endorsement

PURPOSE

The guideline aims to optimize health and quality of life for the post-treatment prostate cancer survivor by comprehensively addressing components of follow-up care, including health promotion, prostate cancer surveillance, screening for new cancers, long-term and late functional effects of the disease and its treatment, psychosocial issues, and coordination of care between the survivor's primary care physician and prostate cancer specialist.

METHODS

The American Cancer Society (ACS) Prostate Cancer Survivorship Care Guidelines were reviewed for developmental rigor by methodologists. The American Society of Clinical Oncology (ASCO) Endorsement Panel reviewed the content and recommendations, offering modifications and/or qualifying statements when deemed necessary.

RESULTS

The ASCO Endorsement Panel determined that the recommendations from the 2014 ACS Prostate Cancer Survivorship Care Guidelines are clear, thorough, and relevant, despite the limited availability of high-quality evidence to support many of the recommendations. ASCO endorses the ACS Prostate Cancer Survivorship Care Guidelines, with a number of qualifying statements and modifications.

RECOMMENDATIONS

Assess information needs related to prostate cancer, prostate cancer treatment, adverse effects, and other health concerns and provide or refer survivors to appropriate resources. Measure prostate-specific antigen (PSA) level every 6 to 12 months for the first 5 years and then annually, considering more frequent evaluation in men at high risk for recurrence and in candidates for salvage therapy. Refer survivors with elevated or increasing PSA levels back to their primary treating physician for evaluation and management. Adhere to ACS guidelines for the early detection of cancer. Assess and manage physical and psychosocial effects of prostate cancer and its treatment. Annually assess for the presence of long-term or late effects of prostate cancer and its treatment.

Progress and controversies: Radiation therapy for prostate cancer

Radiation therapy remains a standard treatment option for men with localized prostate cancer. Alone or in combination with androgen-deprivation therapy, it represents a curative treatment and has been shown to prolong survival in selected populations. In this article, the authors review recent advances in prostate radiation-treatment techniques, photon versus proton radiation, modification of treatment fractionation, and brachytherapy-all focusing on disease control and the impact on morbidity. Also discussed are refinements in the risk stratification of men with prostate cancer and how these are better for matching patients to appropriate treatment, particularly around combined androgen-deprivation therapy. Many of these advances have cost and treatment burden implications, which have significant repercussions given the prevalence of prostate cancer. The discussion includes approaches to improve value and future directions for research.